DTP-43076

Drive Thru Preregistration


    Wilson N Jones Hospital ACCT# 43076

    500 N. Highland Ave

    Sherman, TX 75092

    Hours: 9AM-5PM

    PLEASE CHOOSE YOUR TEST

    *COVID-19, PCR (estimated turn around time 24Hrs-48Hrs): YESNO

    *COVID-19 AG, RAPID (estimated turn around time 1 Hour): YESNO

    * Please choose at least one test

    PERSONAL INFORMATION

    *   *

    *DOB:

    *GENDER: MALEFEMALE

    *

      

    *

    *

    *

    *

    *

    *

    *

    INSURANCE

    *I HAVE INSURANCE
    YESNO

    *

    *

      

    *Insurance Card Photo Front

    *Insurance Card Photo Back

    *Government Issued ID

    *PATIENT RELATIONSHIP TO INSURED

    SELFCHILDSPOUSEOTHER

    *Government Issued ID

    REASON FOR TESTING QUESTIONNAIRE

    I have symptomsI have household member with symptomsWorkSchoolTravelOther

    CoughFever/ChillsShortness of breath/Difficulty breathingMuscle or body acheSore throatAcute sore throatNew loss of smell or tasteDiarrheaNauseaNausea and vomitingVomiting onlyNew fatigue or malaiseRunny nose or congestion

    *Have you had close contact with someone diagnosed with COVID-19? YESNO

    *Have you been notified that you may been exposed to COVID-19? YESNO

    *Recent travel to high prevalence of COVID-19? YESNO

    Personal Medical History, Check if applies:

    Do you have AsthmaCOPDSleep apneaHigh blood pressureHeart issue

    *